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PubMed2005

Overcoming the barriers to effective treatment for attention-deficit/hyperactivity disorder: a neuro-educational approach.

Despite specific diagnostic criteria, published practice guidelines for assessing patients, and the availability of effective pharmacological treatments for children diagnosed with attention-deficit/hyperactivity disorder (AD/HD), a review of prescription practices in the United States indicates that as few as 25-50% of these patients receive even minimal medical treatment for this condition. Because untreated children with AD/HD are at increased risk for psychoactive substance abuse, criminal behavior, and other social problems as adults, the provision of effective care during childhood is essential. In order to clarify the factors impeding treatment during childhood and develop a targeted intervention to overcome these barriers, two studies involving 1514 families were conducted. Each family included one child diagnosed with AD/HD. Factors associated with treatment failure or non-compliance with medical advice included: dissatisfaction with a diagnostic process limited to brief observation, interview, and review of behavior rating scales; fear of stimulant medication; lack of medication response within the first month; development of side-effects during the first month; lack of understanding of the reasons stimulants were being prescribed for a child, and insufficient clinical response. Based on these findings, an intervention program consisting of a comprehensive evaluation process (that included neuropsychological and neurophysiological tests of attention, and medical screening for other health problems associated with inattention and hyperactivity) and parent education about the medical causes of AD/HD, the biochemical action of medications, the relationship between dietary habits and attention, and the educational rights of children with AD/HD was conducted. Following completion of this three session intervention, 95% of patients complied with medical recommendations, initiated pharmacological treatment, and continued medication for a 2-year follow-up period. Three percent of the patients were diagnosed and treated for other medical conditions.

Adolescent↗
PubMed2004

Bridging the language barrier: the use of interpreters in primary care nursing.

Language barriers present a major obstacle to minority ethnic communities accessing primary healthcare. Whereas it is recognised that interpreting services are generally inadequate and inappropriate reliance is placed on family members to interpret, little is known about how nurses working in primary care utilise interpreters to overcome language barriers. The present paper reports on a study examining the utilisation of interpreting services by a range of primary care nurses from the perspectives of the nurses, interpreters and minority ethnic communities. Focus groups were undertaken with five separate groups of district nurses, health visitors, practice nurses, community midwives and specialist nurses, three groups of interpreters from different interpreting services, and five groups of participants from the main community languages in the locality where the study was undertaken (i.e. Arabic, Bengali, Cantonese, Somali and Urdu). Focus group discussions were tape-recorded and subsequently transcribed. Data analysis drew upon the principles of 'framework' analysis. The use of interpreters by primary care nurses varied considerably. Nurses who had received training in using interpreters and who had most control over the timing of patient visits were more likely to use interpreting services. Inadequate training of both nurses and interpreters adversely affected the quality of interaction where interpreters were used. Primary care nurses acted as gatekeepers to interpreting services. Whereas interpreting services were generally perceived to be inadequate, many nurses were accepting of the status quo and prepared to rely on family members to interpret rather than champion the need to improve services.

Communication Barriers↗
PubMed2003

Quality of internet access: barrier behind internet use statistics.

The rapid growth of the Internet is increasingly international with young people being the early adopters in most countries. However, the quality of Internet access looms as a major barrier hidden behind Internet use statistics. The goal of this study was to provide an in-depth evaluation of young people's perspectives on using the Internet to obtain health information and resources (e-health). Using an inductive qualitative research design, 27 focus groups were conducted in Ontario, Canada. The 210 young participants were selected to reflect diversity in age, sex, geographic location, cultural identity and risk. A major finding was how the quality of Internet access influenced young people's ability to obtain health information and resources. Quality of Internet access was affected by four key factors: 1. Privacy, 2. Gate-keeping, 3. Timeliness and 4. Functionality. Privacy was particularly relevant to these young people in getting access to sensitive health information (e.g. sexual activities). Variations in access quality also impacted participation in mutual support, fostering social networks and getting specific health questions answered. These results serve as a warning about using Internet penetration statistics alone as a measure of access. Concerted attention is needed on improving the quality of Internet access for achieving the potential of e-health. This is imperative for addressing the digital divide affecting populations both within countries and globally between countries.

Adolescent↗
PubMed2002

The role of ritualistic ceremonial in removing barriers between subcultures in the National Health Service.

The role of ritualistic ceremonial in removing barriers between subcultures in the National Health Service Background. One of the ways in which it is possible to achieve successful organizational change is through the elimination of those ceremonies that reinforce or preserve the negative aspects of professional and work group autonomy, thus maintaining the barriers between subcultures. Conversely, the encouraging of ceremonies which reinforce positive aspects is likely to achieve more flexible, team-orientated changes. Aim. The paper considers those ceremonies, which perpetuate barriers in a National Health Service (NHS) Trust, and explores new ceremonies which may question, weaken or eliminate current dysfunctional practices. Design. Our research approach was mainly phenomenological, as we wished to elicit the symbolic significance of organizational routines. The primary source of data was spoken language. The findings are based on purposive sampling of informants by means of semi-structured interview and observation. Other types of information were also collected, including business plans, reports and brochures. Informants included the Chief Executive and four Board members, three consultants, the director of nursing and midwifery, 10 middle managers and eight junior, nonmedical and nonmanagerial employees. Findings. Two broad bands of ceremonies have been identified - those which preserve the existing norms and autonomy of professional and worker groups, which we have named Ceremonies of Preservation, and those which encourage change, which we have called Ceremonies of Change. Considerable data are provided to help to 'tell the story'. Conclusion. The paper argues that attention to ceremonial in the wider change process may facilitate the desired, specific change or changes in practice. It suggests that changes which confront unnecessary demarcation, but which do not undermine professional integrity, can create real benefits for NHS hospitals.

Attitude of Health Personnel↗
PubMed2001

Overcoming the language barrier in visual field testing.

PURPOSE: To evaluate the effect of using recorded instructions in patients' native language compared with interpreter-assisted instructions on the reliability and duration of the visual field test. PATIENTS AND METHODS: Sixty patients referred for visual field testing were included in the study. Thirty-five had limited or no knowledge of the Hebrew language, and 25 control patients were fluent in Hebrew, the native language. None had previous experience with automated perimetry. Patients were randomized to receive recorded instructions on the visual field test in their native language or translator-assisted instructions by the technician before performing the test. For each patient, the time required for instructions and test performance and the reliability indices were documented. RESULTS: The method of instruction (recorded or interpreter-assisted) did not affect the time required for patient instructions (66 +/- 24 seconds and 57 +/- 30 seconds, respectively), the time for test performance (7.2 +/- 1.5 minutes and 7.8 +/- 1.8 minutes, respectively), and test reliability as measured by the rate of fixation losses. Regardless of the method of explanation, the time required for instructions and for performing the test were significantly shorter for Hebrew speakers than for non-Hebrew speakers. CONCLUSION: The use of a recorded explanation in the patient's native language before visual field testing is an applicable method for patient instruction. Clinics in areas with multilingual populations may use this method to save technicians time, without adversely affecting the time required for performing the test and its reliability.

Aged↗
PubMed2002

Administrative barriers reduce emergency physician ordering of nasal and acromioclavicular joint radiographs.

The objective of this study was to determine whether administrative barriers to clinician ordering of nasal bone and acromioclavicular (AC) joint radiographs would result in a significant diminution in emergency department use of these films and in patient charges. This study involved a retrospective cohort or pre-post analysis of radiograph ordering by emergency care providers seeing adult patients with nasal area or shoulder injuries. Numbers of films ordered before and after enactment of a restrictive policy change were determined, as well as any charge reductions associated with diminished film use. For each radiograph type, there was a 1-year preintervention period, and 2 subsequent 12-month periods after the policy change. Nasal bone radiographs decreased from 166 in 1994 to 10 in 1995 and 4 in 1996 (P <.001, chi(2)). This resulted in potential annual charge savings of 33,176 dollars. AC joint radiographs decreased from 35 films in 1994 to 5 in 1995 and 8 in 1996 (P <.001, chi(2)), with potential annual charge savings of 6,578 dollars. Adoption of an interdepartmental policy that prohibits physicians from routinely ordering radiographs of limited clinical value can result in significant reduction of radiograph use. This drop in use can lead to considerable reductions in patient charges.

Acromioclavicular Joint↗
PubMed2002

Barriers to prompt and effective treatment of malaria in northern Sri Lanka.

BACKGROUND: For the past 18 years, northern Sri Lanka has been affected by armed ethnic conflict. This has had a heavy impact on displacement of civilians, health delivery services, number of health professionals in the area and infrastructure. The north of Sri Lanka has a severe malaria burden, with less than 5% of the national population suffering 34% of reported cases. Health care providers investigated treatment-seeking behaviour and levels of treatment failure believed to be the result of lack of adherence to treatment. METHODS: Pre- and post-treatment interviews with patients seeking treatment in the outpatient department (OPD) and focus groups. RESULTS: A total of 271 persons completed interviews: 54.4% sought treatment within 2 days of the onset of symptoms, and 91.9% self-treated with drugs with prior to seeking treatment, mainly with paracetamol. Self-treatment was associated with delaying treatment (RR 3.55, CI 1.23-10.24, P=0.002). In post-treatment interviews, self-reported default was 26.1%. The main reasons for not taking the entire regimen were side-effects (57.6%) and disappearance of symptoms (16.7%). Focus groups indicated some lack of confidence in chloroquine treatment and prophylaxis, and scant enthusiasm for prevention methods. CONCLUSIONS: A number of factors contribute to a lack of access and a lower quality of care for malaria: lack of medical staff and facilities because of the fighting; lack of confidence in treatment, and perception of malaria as a routine illness. Prevention efforts need to take into account certain beliefs and practices to be successful.

Adolescent↗
PubMed2004

The talking touchscreen: a new approach to outcomes assessment in low literacy.

PURPOSE: Cancer patients who are deficient in literacy skills are particularly vulnerable to experiencing different outcomes due to disparities in care or barriers to care. Outcomes measurement in low literacy patients may provide new insight into problems previously undetected due to the challenges of completing paper-and-pencil forms. DESCRIPTION OF STUDY: A multimedia program was developed to provide a quality of life assessment platform that would be acceptable to patients with varying literacy skills and computer experience. One item at a time is presented on the computer touchscreen, accompanied by a recorded reading of the question. Various colors, fonts and graphic images are used to enhance visibility, and a small picture icon appears near each text element allowing patients to replay the sound as many times as they wish. Evaluation questions are presented to assess patient burden and preferences. RESULTS: An ethnically diverse group of 126 cancer patients with a range of literacy skills and computer experience reported that the 'talking touchscreen' (TT) was easy to use, and commented on the usefulness of the multimedia approach. CLINICAL IMPLICATIONS: The TT is a practical, user-friendly data acquisition method that provides greater opportunities to measure self-reported outcomes in patients with a range of literacy skills.

Adult↗
PubMed2005

International public health research involving interpreters: a case study from Bangladesh.

BACKGROUND: Cross-cultural and international research are important components of public health research, but the challenges of language barriers and working with interpreters are often overlooked, particularly in the case of qualitative research. METHODS: A case-study approach was used to explore experiences of working with an interpreter in Bangladesh as part of a research project investigating women's experiences of emergency obstetric care. THE CASE STUDY: Data from the researcher's field notes provided evidence of experiences in working with an interpreter and show how the model of interviewing was adapted over time to give a more active role to the interpreter. The advantages of a more active role were increased rapport and "flow" in interviews. The disadvantages included reduced control from the researcher's perspective. Some tensions between the researcher and interpreter remained hard to overcome, irrespective of the model used. Independent transcription and translation of the interviews also raised questions around accuracy in translation. CONCLUSION: The issues examined in this case study have broader implications for public health research. Further work is needed in three areas: 1) developing effective relationships with interpreters; 2) the impact of the interpreter on the research process; and 3) the accuracy of the translation and level of analysis needed in any specific public health research. Finally, this paper highlights the importance to authors of reflecting on the potential impact of translation and interpretation on the research process when disseminating their research.

Adolescent↗
PubMed2001

Overcoming barriers to hepatitis B immunisation by a dedicated hepatitis B immunisation service.

AIMS: To determine the effectiveness of a selective hospital based hepatitis B immunisation programme and the barriers to be overcome in obtaining a successful outcome. METHODS: Retrospective case note review of 265 infants born over a five year period to hepatitis B carrier mothers at a university affiliated hospital in Hackney, London. RESULTS: A total of 242 infants (91%) were fully vaccinated; 217 (82%) had serology; 31 required booster doses. Percentages failing to reach second, third vaccinations, and serology on schedule rose exponentially (7%, 18%, 33% respectively). Mobility was high (25%) and significantly affected outcome. A total of 95% Hackney resident babies were fully vaccinated compared with 78% non-residents. Uptake of routine immunisations was higher in Hackney residents than non-residents and greater in those who were eligible for hepatitis B vaccine. Name changes occurred in 35%. Translation requirements were high (85% for Turkish, Vietnamese, and Asian families). Requirements for specific postnatal counselling of mothers and hepatology referral fell significantly during the course of the study. Only seven of 22 babies born in 1995 in Tower Hamlets compared with 53 of 58 Hackney babies received a full vaccination course in non-hospital based primary care. CONCLUSION: In inner city areas with high prevalence of hepatitis B carriage, mobility, and diverse ethnicity, a dedicated centralised immunisation service can be highly effective, provided that adequate support services (translation, counselling, and parental referral) are available.

Africa↗
PubMed2006

Barriers to colorectal cancer screening among Medicare consumers.

BACKGROUND: Few studies have examined lack of physician recommendation and other reasons for under-utilization of colorectal cancer (CRC) screening in the Medicare population. METHODS: Data from a telephone survey conducted in 2001 in a random sample of Medicare consumers residing in North and South Carolina were used to examine barriers to CRC screening, focusing on consumers' reports of receiving a physician's recommendation to obtain CRC screening and reasons for not being screened. Analyses were restricted to respondents with no history of CRC (n = 1901). Descriptive statistics were used to characterize respondents' CRC screening status, receipt of a physician's recommendation for screening, and reasons for not being screened. Logistic regression modeling was used to examine factors associated with receiving a physician recommendation for fecal occult blood test, sigmoidoscopy, colonoscopy, any endoscopy, and any CRC test. RESULTS: Thirty-one percent of Medicare consumers had never been tested for CRC, and 18% had been tested but were not current with Medicare-covered intervals. Overall, 28% reported not receiving a physician recommendation for screening. Predictors of receiving a physician recommendation included sociodemographic (younger age, white race, more education), health status (increased CRC risk, comorbidity), and healthcare access (had a routine/preventive care visit in the past 12 months) factors. Lack of knowledge/awareness and the physician not ordering the test were commonly cited reasons for not having CRC tests. CONCLUSIONS: Colorectal cancer screening was under-utilized by Medicare consumers in two states, and lack of physician recommendation was an important contributing factor. Providing a benefit under the Medicare program does not ensure its widespread use by consumers or their physicians.

Aged↗
PubMed2004

Inadequate functional health literacy in Spanish as a barrier to cervical cancer screening among immigrant Latinas in New York City.

INTRODUCTION: The objective of this study was to examine the association between inadequate functional health literacy in Spanish among low-income Latinas aged 40 and older and cervical cancer screening knowledge and behavior. METHODS: Spanish-speaking Latinas aged 40-78 of various nationalities (n = 205) participated in a study that included a survey on cervical cancer knowledge and behavior administered in Spanish and the Spanish version of the Test of Functional Health Literacy in Adults. RESULTS: Compared to those with adequate and marginal health literacy, women with inadequate functional health literacy in Spanish were significantly less likely to have ever had a Papanicolaou (Pap) test (odds ratio, 0.12; 95% confidence interval [CI], 0.04-0.37) or in the last three years (odds ratio, 0.35; 95% CI, 0.18-0.68) and were significantly more likely to have had their last Pap test at a local public hospital (odds ratio, 2.43; 95% CI, 1.18-4.97). Even when controlling for other factors, women with inadequate health literacy were 16.7 times less likely (adjusted odds ratio, 0.06; 95% CI, 0.01-0.55) to have ever had a Pap test. CONCLUSION: Almost half of the population we studied will have difficulty interpreting written medical materials, even in Spanish. When developing efforts to reach women who have not been screened, programs and service providers need to be aware that the women most in need of information about screening may be more likely to be unable to read any written materials provided to them, regardless of the language or level of simplicity of the materials. Programs and strategies need to be implemented to increase screening prevalence and to minimize the identified gaps in regular screening for Latinas who have low health literacy.

Adult↗
PubMed2000

Sexual health and the practice nurse: a survey of reported practice and attitudes.

BACKGROUND: Practice nurses have an important role in the provision of sexual health services in general practice. AIM: This study set out to determine practice nurses' reported practice and training in sexual health, attitudes towards sexual health, barriers to discussing sexual health with patients, and training needs. METHOD: A confidential self-administered postal questionnaire survey was sent to all 298 practice nurses in one English health district (Leicestershire). RESULTS: Completed questionnaires were returned by 234 practice nurses (response rate 79%). Most nurses routinely offered well-person checks (90%), cervical smears (89%), travel clinics (83%), saw women with genito-urinary symptoms (77%) and offered family planning advice (54%). Only a minority of nurses (13%) offered specific teenage health clinics. Sexual health issues were always discussed in a majority of consultations when giving family planning advice (65%) and in women with genito-urinary symptoms (58%). Most practice nurses (62%) had undertaken at least one course dealing with sexual health issues in the last 5 years. Uptake of training was, however, significantly lower in certain groups of nurses. An analysis of the attitude statements suggested that nurses were more comfortable discussing sexual health issues with female patients and teenagers than with male patients and those of different sexual orientations. Nurses who had received training reported more positive attitudes towards discussing sexual health issues with patients. CONCLUSION: Practice nurses offer a wide range of services in which the need to be able to take a sexual history and offer appropriate advice is important. There is scope to improve the provision of sexual health services by nurses in general practice, particularly in relation to services for teenagers.

Adolescent↗
PubMed1999

Breast cancer screening in relation to access to health services.

PURPOSE/OBJECTIVES: This study examined mammography screening and breast self-examination (BSE) in relation to perceived access to health services to identify persistent barriers to earlier detection. DESIGN: Community-based, cross-sectional, survey, and interview. SETTING: More than 80 nonhealthcare-related, women's group settings in northern California. SAMPLE: Convenience sample of 838 black/African American, Latina/Hispanic, and Caucasian/Anglo women varying in age, annual family income, sexual orientation, and educational history. METHODS: Survey and interview (in English or Spanish) by on-site research assistants facilitating participation of women with limited reading capability. MAIN RESEARCH VARIABLES: Perceived access to services, breast cancer screening behaviors, acculturation and spoken language, habits of use, perceived prejudice in health delivery, available economic resources, and other social and behavioral variables reported elsewhere. FINDINGS: Healthcare habits, the perception of prejudicial treatment in health service delivery, spoken language, and three different measures of financial capability explained a large degree of perceived access to services. Perceptions of a lack of access to services were related to decreased mammography screening participation and to decreased BSE behavior. CONCLUSIONS: Participation in cancer screening depends on real economic access and previous health service delivery experience. BSE behavior may be influenced by lack of money to pay for healthcare services, and experienced prejudice in healthcare delivery appears to have a lasting influence on mammography screening behavior. IMPLICATIONS FOR NURSING PRACTICE: Tolerance and culturally sensitive service delivery coupled with economic access to both screening and necessary treatment will be vital to eliciting women's complete participation in attaining desired earlier detection goals for breast cancer.

Adult↗
PubMed1997

Long-term follow-up in outpatient clinics. 2: The view from the specialist clinic.

BACKGROUND: Most of the patients seen in outpatient clinics are in follow-up. Waiting times for patients requiring first appointments would be shorter if more patients were discharged to the care of their GPs. OBJECTIVE: To identify opportunities and barriers to discharge of patients from follow-up in medical outpatient clinics and describe the use of discharge criteria to facilitate discharge. METHOD: General medical clinics held by five consultants in a district general hospital in Manchester were observed by the research team. Discussion groups were held with specialists to explore their views on barriers to and opportunities for discharge from outpatient care. Data from the hospital information system were used to compare discharge rates before, during and after the introduction of discharge criteria. RESULTS: Discharge consultations were inconsistently handled, and patients were not always aware that they had been discharged. Specialists were ambivalent about discharging patients, and uncertain about the care these patients would receive in general practice. Use of structured discharge criteria appeared to improve the quality of discharge consultations, and may have increased the proportion of patients discharged. Specialists were concerned about the work involved in giving detailed feedback to patients and GPs about patients' management needs after discharge. CONCLUSIONS: There are a number of issues arising from the findings of our study concerning the discharge of patients from long-term outpatient follow-up which purchasers of outpatient services may wish to consider. Referral letters should spell out clearly reasons for referral and the expectations of the GP. Discharge consultations should be accorded higher priority, and allocated sufficient time. It may sometimes be appropriate to prepare a patient for discharge at the previous visit. The reason for discharge should be made clear to patients. All discharges should be accompanied by a management plan for the GP, including arrangements for gaining further access to specialist care when needed in the future. Providing written information for patients in lay language would improve the process of discharge, and would allow patients to share the responsibility for their on-going care.

Ambulatory Care↗
PubMed2003

Cigarette smoking among Chinese Americans and the influence of linguistic acculturation.

Less acculturated Chinese Americans experience cultural and language barriers. The present study assessed the relationship between linguistic aspects of acculturation and cigarette smoking among Chinese Americans. A cross-sectional, self-administered survey was administered to a consecutive sample of 541 Chinese American adults (aged 18 years or older) attending four pediatric, medical, or dental practices located in Philadelphia's Chinatown from November 2000 to February 2001. Linguistic acculturation was measured by adapting a reliable and valid acculturation scale developed for Southeast Asians. English and Chinese language proficiency subscales were utilized to analyze the association between language proficiency and current smoking. Whereas 25% of Chinese American men reported current smoking, only 3% of Chinese American women reported current smoking. Chinese American men with lower English proficiency reported significantly higher rates of current smoking compared with Chinese American men with a higher level of English proficiency (33% vs. 18%, p<.01). Less English-proficient Chinese American male smokers were less likely to have received advice from a physician to quit smoking (50% vs. 85%, p=.01). In multivariate analysis, increased English proficiency was associated with decreased odds of current smoking (OR=0.38, 95% CI=0.16-0.89) among Chinese American men after controlling for confounding variables. In conclusion, higher English proficiency was associated with decreased current smoking among Chinese American men. Chinese American men with limited English proficiency should especially be targeted for tobacco control interventions. Further research is needed to assess whether acculturation is associated with smoking among Chinese American women and with use of smoking cessation treatments and services by Chinese American smokers.

Adult↗
PubMed2005

Diabetes in children and adolescents from ethnic minorities: barriers to education, treatment and good metabolic control.

AIM: This paper reports an investigation to establish whether metabolic control is different in children and adolescents from ethnic minorities with type 1 diabetes compared with young Danish patients, and to learn about factors affecting their opportunities to achieve good metabolic control. BACKGROUND: The prevalence of diabetes in children and adolescents from ethnic minorities in Denmark is increasing. Having a different ethnic background has frequently been described as a risk factor for poor metabolic control, but whether the risk is represented by the ethnicity and immigration itself or in combination with other factors is unclear. METHODS: The study included data (gender, age, diabetes duration HbA(1c), number of incidents of severe hypoglycaemia and ketoacidosis) from a national register including 919 Danish and 58 children and adolescents from ethnic minorities, questionnaires to all 20 Danish paediatric diabetes centres and questionnaires to 38 families of other ethnic backgrounds completed by professional interpreters. The study was conducted in 2001-2002. RESULTS: HbA(1c) was significantly higher in children and adolescents from ethnic minorities (mean 9.05 +/- 1.4%) compared with Danish patients (mean 8.62 +/- 1.3%; P = 0.018). There was no significant difference in HbA(1c) among the different ethnic groups, nor in the prevalence of severe hypoglycaemia or ketoacidosis. Patients from different ethnic minorities were unevenly distributed throughout the country, and generally the centres provided limited specialized knowledge and support. The questionnaires completed by the parents revealed limited schooling, lack of professional education and a major need for interpreters; these characteristics were especially prevalent among the mothers. CONCLUSIONS: Young patients from ethnic minorities have significantly poorer metabolic control compared with Danish patients, and patients with an immigrant background are seen as a vulnerable group with different needs and probably fewer chances of achieving good control. Special education for health care professionals as well as projects to improve methods, quality and knowledge should be encouraged in order to provide tailored support to members of individual ethnic groups. We recommend that the use of professional interpreters should become the gold standard in health care provision to all immigrant families.

Adolescent↗
PubMed2000

Barriers to care for patients with neurologic disease in rural Zambia.

The awesome burden of treatable yet untreated neurologic disease in the developing world presents a humanitarian crisis to those of us with neurologic expertise from more privileged situations. Although increased economic resources are critically needed, a shortage of personnel to care for these patients is as great a problem. It is neither feasible nor desirable to propose training neurologists to work in these regions. However, COs could be selected to receive additional training and return to their home regions to serve as resources for referrals and as community educators. Such a training program would not require massive financial commitments. A handful of dedicated neurologists could conceivably accomplish this in 6- to 8-week training sessions. Ideally, educational materials, such as posters and pamphlets in both English and the native language of the various regions, would be provided at no cost. Existing textbooks in neurology are written for physicians and often focus on diagnostic evaluations and therapies far beyond the services available in developing countries. A text for practical use by COs and community health workers that discusses the application of available medicines and therapies for common neurologic problems would be invaluable. Similar books exist that address general medical and obstetrical problems (for example, Where There Is No Doctor: A Village Health Care Handbook). Where There Is No Neurologist could be developed as a primary teaching tool and a valuable reference for COs with neurologic expertise. Neuroscience researchers, clinical neurologists, and neurology residents from industrialized countries have much to offer and to gain by working in the Third World. Research to monitor the incidence and resource utilization of emerging problems such as stroke is needed to influence public policy. The economic burden and lost productivity caused by neurologic disease in this part of the world has not been appreciated or explored. Disease beyond the scope of Western experience manifests daily in places like Chikankata. Entities such as tabes neurosyphilis, which previous generations of neurologists used as the basis for their training, still abound in Zambia. Much personal satisfaction can be gained in providing care to this vulnerable and underserved population.

Adult↗